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Eform

Please fill out all the necessary information on this form and click on SUBMIT FORM at the bottom of the page; when you sign the bottom of this page you agree that you are happy for your information to be used by any dentist/staff member in accordance with your treatment.

Do you or have you ever suffered from any of the following? If so, please elaborate in the space provided.
BY SIGNING THIS FORM, I UNDERSTAND ALL ACCOUNTS ARE TO BE PAID ON THE DAY OF TREATMENT IN FULL
I confirm that when attending the clinic I will ensure I have no symptoms of Covid-19 and have not been in contact with anyone with Covid-19 and consent to a temperature check onsite.
We endeavour to provide a service to meet all of your dental requirements, to assist us in this we ask you to please fill out the questionnaire below:
Please click any other of the following services or treatment options you may wish to discuss with your dentist:
Teeth whitening
Orthodontics or straightening of the teeth
Cosmetic treatment to enhance your smile
Replacing missing teeth
Preventative dentistry
Financing options/ Payment Plans
Please speak to your dentist about any concerns you may have in regards to any available treatments. We are able to provide a written quote to you at the end of your initial consult.
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